A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?
A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions
A 3-year-old child who has an atrial septal defect and a heart rate of 120/min
A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL
A 2-year-old child who has diarrhea and reports abdominal pain
The Correct Answer is A
A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Choose the client's dominant arm for IV access whenever possible. The nondominant arm is preferred to minimize interference with daily activities.
B. Select a site proximal to previous venipuncture sites. This is the appropriate action because using a site above a previous one ensures better vein integrity and reduces complications.
C. Initiate IV access on the palmar side of the client's wrist. This site should be avoided as it is more painful and increases the risk of nerve damage.
D. Insert a larger gauge IV catheter to prevent phlebitis. A smaller gauge catheter is preferred when possible, as larger catheters can increase the risk of vein irritation and phlebitis.
Correct Answer is B
Explanation
A. Breathlessness is not a typical symptom of a sliding hiatal hernia. However, in severe cases, large hernias may cause shortness of breath due to pressure on the diaphragm.
B. Heartburn (acid reflux) is a common symptom because the hernia allows stomach acid to move up into the esophagus, causing irritation and discomfort.
C. Abdominal cramping is not a primary symptom of a sliding hiatal hernia. Cramping is more commonly associated with gastrointestinal conditions like irritable bowel syndrome (IBS) or gastroenteritis.
D. Constipation is not directly linked to a sliding hiatal hernia. Instead, symptoms usually involve gastroesophageal reflux disease (GERD)-related issues, such as heartburn and regurgitation.
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